A more ‘failsafe’ approach to difficult intubation with the gum elastic bougie

The gum elastic bougie is frequently used to facilitate difficult intubation, but sometimes fails due to oesophageal placement. When this occurs, the bougie is either reinserted, or an alternative airway management technique used. We suggest another option: leaving the bougie in the oesophagus and using it as a guide to insertion of the Pro-Seal laryngeal mask airway™ (PLMA™) [1]. This technique is quick and simple using the following steps: The distal␣end of the PLMA™ drainage tube is lubricated by squeezing a water-based gel into it; the drainage tube is threaded over the bougie until it protrudes from the proximal end; the PLMA™ is railroaded along the bougie, either following the palatopharyngeal curve using the index finger, or more directly using a laryngoscope; the cuff is then inflated and ventilation commenced. Our combined successful experience of the bougie-PLMA™ technique in 25␣consecutive elective cases suggests that the bougie not only helps guide the PLMA™ into its correct location, but also reduces impaction at the back of the mouth. The technique can be practiced on routine cases provided there is no known oesophageal pathology. It may also be useful backup technique if the PLMA™ becomes folded over during insertion [2]. C.